Scleral fixation without conjunctival dissection

Abstract

The article by Hoffman et al.1 describes a technique for suturing an intraocular lens (IOL)–capsular bag decentration without conjunctival dissection. This surgical technique is similar to others published by Ahmed et al.2 and us,3 but it eliminates the need for conjunctival dissection, scleral cauterization, and conjunctival stitches. However, we believe that some of the surgical maneuvers described by Hoffman et al. could be improved. First, Hoffmann et al. describe a 27-gauge needle that is passed through the conjunctiva and sclera and inserted into the eye behind the capsular bag equator in the area of the dislocation. The needle perforates the capsular bag central to the IOL haptic and passes completely through the posterior and anterior capsules. The second arm of the double-armed polypropylene (Prolene) suture is then passed through the opposite paracentesis and docked with the 27-gauge needle (Figure 4 in the article). We believe this maneuver is dangerous because the IOL–capsular bag is dislocated and moves. When the capsular bag is pushed with the 27-gauge needle, the zonular damage and IOL–capsular bag dislocation may increase. In our opinion, it is better to perforate the anterior and posterior capsules with the 10-0 Prolene suture needle and push the IOL–capsular bag in the direction of the dislocation than push in the opposite direction with the 27-gauge needle, which increases the possibility of further dislocation (Figure 1).2Figure 1: A 10-0 Prolene suture needle is inserted into the eye and the IOL–capsular bag is pushed in the same direction as the dislocation (arrow), thus avoiding increased zonular damage. At the same time, a spatula is introduced through the opposite incision to provide counterpressure and facilitate penetration of the anterior and posterior capsules with the 10-0 suture needle.Second, we believe it is very difficult to penetrate the posterior and anterior capsules by simply pushing the dislocated capsular bag because the capsular bag moves when it is pushed. We suggest grasping the IOL–capsular bag through a temporal incision using Kelman forceps.2 Another possibility is to insert a spatula through the opposite incision to provide counterpressure when the needle is passed through the peripheral capsule to loop and stabilize the IOL–capsular bag (Figure 1).3,4 With both methods, it is necessary to use a second instrument to stabilize the IOL–capsular bag. Finally, Hoffman et al. describe the 27-gauge needle passed through the conjunctiva and the full thickness of the scleral pocket 1.0 mm posterior to the surgical limbus. If the eye has a deep anterior chamber and the IOL–capsular bag is sutured only 1.0 mm posterior to the surgical limbus, a tilted IOL may result. In cases of high myopia, the anterior chamber is deep and the IOL–capsular bag may have to be sutured 2.0 mm posterior to the surgical limbus. In that case, retrieving the Prolene suture through the scleral pocket incision using a Sinskey hook and tying a knot could be more complicated. Performing a conjunctival dissection and creating a scleral flap might be a better technique. Despite disagreeing with certain aspects of the surgical technique of Hoffmann et al., we believe it is a step forward in refining scleral fixation of the IOL–capsular bag and increasing patient comfort.